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Prevention is impractical, but try telling that to the PM

Prevention is better than cure,” the Prime Minister said yesterday, not once, but three times.

He has made much of the fact that currently we spend only 2% of our healthcare funding on prevention. Yesterday’s health reform report proposed a new, independent National Health Promotion and Prevention Agency and “shifting the curve” of health spending toward prevention.

In fact prevention has been fashionable for most of this decade. It is a health economist’s dream given the ageing of the population and the growth of chronic diseases: invest more now and there will be long-term payoffs in reduced hospital admissions, smaller primary care costs and greater “wellness”.

Well, maybe. But, with respect to the Prime Minister, prevention is not better than cure. Not if it costs more, and not if it costs more in terms of the overall net benefit to the patient.

There’s a body of work that suggests prevention isn’t always, or even usually, better than cure. A New England Journal of Medicine literature review last year found a huge variation in the cost-effectiveness of preventative measures (measured in cost per “quality-adjusted life-year”) and that they didn’t differ markedly from treatments in their cost-effectiveness. Some preventions and treatments led to lower overall costs. A small number actually cost more and led to poorer outcomes. The rest were in between.

Another US article teases out why this is the case. Prevention covers a huge range of measures, from advertising campaigns to encourage exercise, to screening (and frequent or less frequent screening), to vaccination and treatment for risk factors like cholesterol. They obviously vary enormously in cost — and costs can be measured in different ways. Do you count only the cost to the health funder? What about the cost to patients in time as well? A simple preventative measure like taking aspirin for heart conditions, or treatment to help smokers quit, cost little but can have big benefits or actually save money. Mass-screening programs, especially if they’re annual, are far less cost-effective. Some vaccination programs are very cost-effective for certain populations, not everyone. Cholesterol-lowering medication in certain groups yields poor results for the cost of the program.

To be fair to the Commission, it is not advocating any sort of simple shift in favour of prevention — it wants a similar evaluation framework for preventative measures compared to that used to assessing treatments.

But “shifting the curve” of health funding toward prevention means, necessarily, less funding for treatment programs. That means identifying what will receive less funding. Would you be happy to see $200m redirected from public hospitals to fund a “social marketing campaign” of TV ads encouraging people to exercise more? Especially when the ultimate effect of the campaign in terms of healthier Australians will never be known?

It’s not just coke-snorting ad executives who would benefit from a greater emphasis on prevention. There are any number of lobby groups and “research institutes”, not to mention large companies like those in the weight-loss industry, who would be only too happy to get access to an increase in preventative health funding. These people are rentseekers just like those in other industries like manufacturing who argue that the community will benefit if they get a handout. They will appear as eloquent, disinterested advocates of greater preventative health funding in debates over the Commission report, when they are anything but.

Worse, a good number of such people are ardent regulators. The behavioural change end of the preventative health spectrum has a strong whiff of social engineering about it. People who want to ban certain forms of advertising, or ban certain foods, or impose punitive taxes on sinful products, or ban urban sprawl or spend vast amounts of money on unused bike paths.

Now, before you go accusing me of being a libertarian wingnut, the problem with such advocates is not that of big government versus small government, but of the demonstrated effectiveness of such measures. A ban on advertising of junk food, while cost-free, infringes the rights of broadcasters and advertisers, and even those contemptible hypocrites should be afforded the protection of free speech; moreover, there is no evidence from places like Sweden or Quebec that such bans have any impact on obesity. Heavy investment in bike infrastructure, which does have a cost, may not translate into long-term rises in bicycling because transport choices are driven by other factors like family and work commitments.

Moreover, the costing of such measures frequently only includes the cost to taxpayers or medical funders of changed behaviour, and doesn’t include the cost in time and money to users themselves.

In short, some preventions are better than cures. Others don’t even prevent what they’re supposed to prevent. If we’re going to spend less on treatment and more on prevention, we’d better make sure we’re funding the right preventions.

16
  • 1
    Stiofan
    Posted Tuesday, 28 July 2009 at 1:18 pm | Permalink

    10/10!

    In fact, why not go the whole hog and expose the complete and utter waste of Government funds across a whole range of dubious informational activities, ranging from the ad campaigns against domestic violence to the flood of glossy (and largely unread) annual reports from every government agency?

  • 2
    Posted Tuesday, 28 July 2009 at 1:39 pm | Permalink

    Good article Bernard, but I still would rather have bike paths than not. (though agree it’s dodgy to claim them as “health spending”

  • 3
    stephen martin
    Posted Tuesday, 28 July 2009 at 1:42 pm | Permalink

    Some educational programs appear to work, for example quit smoking campaigns. Exercise programs and education starting at school would surely be beneficial to the long term health of children as they become adults,and could be incorporated into the curriculum (possibly they already are in some schools)

  • 4
    David Sanderson
    Posted Tuesday, 28 July 2009 at 1:52 pm | Permalink

    Surely there is an unaddressed definition problem here. I, for one, would not have included spending on cholesterol-lowering drugs as part of the preventative health spend. Such treatments are more like the treatments for chronic conditions. Preventative health spending is mostly about the encouragement of behavioural changes (as outlined above).

    The idea that McDonalds, KFC and Hungry Jacks should have untramelled speech rights seems pretty fanciful. Obviously, their abilities to impose huge amounts of their ‘speech’ on to us is a function of their massive financial muscle. If we are going to allow them untrammeled rights to dishonestly (‘misleadingly’ is too euphemistic a term) promote their products then it would be equally fair and democratic to allow real estate property owners to build whatever they damn well please on their properties.

    Unlimited advertising is not free speech but unlimited property rights. We don’t allow unlimited real estate property rights, because of the community harm that would cause, so why should we allow the unlimited development of business properties (ie products and brands) regardless of the harm they cause?

  • 5
    michael crook
    Posted Tuesday, 28 July 2009 at 2:04 pm | Permalink

    Well said David. Bernard, we really need to look at countries where community based medicine is proving its effectiveness. According to WHO statistics, (and Sicko) France has the most cost effective and “best” health system in the world. Community based health care in Cuba and Venezuela (which I experienced last year) provide very effective outcomes by training doctors to work within their own communities, a large part of which is preventative. Even the unfairly maligned British national Health Service rates far higher than our own both in service delivery and outcomes. We need to get the profit motive out of medicine, let the specialists buy a new porsche every 2 years, instead of every year, take the corporates out of the equation completely and consign the health insurance industry to the dustbin of history. PS have a look at the editorial in last weeks Green Left Weekly about the Cuban doctors working in East Timor.

  • 6
    Stiofan
    Posted Tuesday, 28 July 2009 at 2:06 pm | Permalink

    Yep, when all else fails, beat up on McDonalds!

    David, your response is just a rant, unless you’re willing to say where you would draw the line on free speech. Your analogy with “real estate property rights” demonstrates this very clearly. The “community harm” that is often cited as a reason for restricting real estate property rights is too often a cover for private interests (more often than not, competing real estate property rights).

  • 7
    Scott Grant
    Posted Tuesday, 28 July 2009 at 2:13 pm | Permalink

    I dispute the claim that corporate advertising has anything to do with free speech. It is far from free monetarily, and for that reason alone it is not free in the other sense.

    I would be quite happy to see junk food advertising banned. I like bike paths and I use bike paths, and to call it a “heavy” investment alongside road and rail is more than a bit disingenuous. Some things are just the right thing to do, whatever libertarian wingnuts wish to preach.

    But I would agree that doing these things in the name of preventive medicine ought to require some concrete evidence of benefit.

  • 8
    Harry Mavros
    Posted Tuesday, 28 July 2009 at 2:47 pm | Permalink

    The elephant in the room here is the epistemological uncertainty that attends preventative health measures. In short, health “authorities” rarely know with any degree of certainty what causes health problems, and therefore, what remedy will work to prevent them.

    This will no doubt come as a shock to many people, who understandably trust that the “authorities” by virtue of their qualifications, letters after their name, and carefully crafted gravitas, have all the answers. Nothing could be further from the truth.

    Take, for instance, the biggest killer of Australians - cardiovascular disease (CVD). Surely, the authorities know what causes it, and therefore, how to prevent it? Hardly.

    Time after time, studies show that the preventative measures preached by the mainstream (i.e. avoiding saturated fats, eating a diet high in carbohydrates, increasing exercise to up to 5 hours/week) have yielded next to zero impact in preventing CVD. At the same time, studies have shown that diets high in fats and proteins, and low in carbohydrates, help to reduce obesity, improve blood sugar profiles and decrease blood triglycerides.

    Ok, so which message gets the tag as “preventative”?

    If the facts are contestable (and in so many cases, they surely are), then throwing buckets of money at preventative measures that may well be useless is not only wasteful, but bloody dangerous. Until we have secured more certainty on these issues (as we have on issues such as the smoking - lung cancer link), then treating the symptom actually makes more sense (counter-intuitive as it may be).

  • 9
    Jenny Haines
    Posted Tuesday, 28 July 2009 at 3:10 pm | Permalink

    As a nurse of 32 years experience in the health system in a variety of roles, it still continues to amaze me that people understand so little about their health, and how to maintain it and what to do when they get sick. Prevention needs to be largely about educating people on what they need to do to stay healthy at all stages of their life, and the simple and basic measures they can take when they get sick to stop themselves getting sicker, eg the recent swine flu pandemic - simple measures like resting in bed, checking your body temperature regularly, drinking plenty of fluids, are all measures that in the past your mother would have taught you but now with the breakdown of the extended family into the nuclear and sub nuclear family, these messages do not seem to be transmitting from one generation to the next. This raises the question about health education in schools and universities, but would the students listen and retain, or just see it as more information that you learn for an exam, and forget immediately after. TV ads only work to a certain extent, so no I would not like to see money taken away from acute services to encourage people to exercise more. It would be a waste of money. But building a preventative approach into each persons learning for life, whether at school, university, church, holiday camp or whatever, seems to me to be the way to go.

  • 10
    stephen martin
    Posted Tuesday, 28 July 2009 at 3:47 pm | Permalink

    From previous posts I know , at least I think I do, that Harry Mavros is a doctor,I wonder does he have an explanation for the falling CVD in Australia. From what he has just written it appears that CVD is something of a mystery. Studies apparently do not show that either exercise or diet has a noticeable beneficial effect of health. Surely falling smoking rates can not be entirely responsible?

  • 11
    Harry Mavros
    Posted Tuesday, 28 July 2009 at 4:16 pm | Permalink

    CVD is not in decline; rather, cases of mortality arising from CVD are in decline. Mortality, not prevalence.

    To translate, we are getting better at prolonging the life of people with artherosclerosis and getting better at treating people after their first, second etc. myocardial infarctions. The actual cases of CVD (expressed as a percentage of the population in each age cohort) are actually slightly on the rise.

    And, it is not the case that the causes of CVD are a complete mystery; it is that they are contestable. That is to say, the low-fat and diet proponents who have held sway in terms of public health for the last three decades will continue to preach their mantra despite the mountains of controlled studies that demonstrate that it does not work. But, despite this, the power of conventional wisdom and cognitive dissonance is such that every disconfirmation is merely dismissed as an ‘outlier’ (remember Ancel Keys’ notorious Seven Nations Study - whatever happened to the other 14 nations?!) or is a result of ‘unknown variables’ (e.g. red wine consumption is put up as the variable that explains the low rates of CVD in high saturated-fat-eating France, despite the fact that Italians drink just as much of it, and die of CVD in droves!).

    The take-home message is; the public health “authorities” pass off as knowledge what is their best guess (and, if one is to be cynical, what serves their interets - there is big, big money in preventative health - note the Heart Foundation’s tick of approval!). At best, preventative health measures based on these contestable theories are wasteful, at worst they could be catastrophic.

    BTW, I’m not a doctor of medicine.

  • 12
    stephen martin
    Posted Tuesday, 28 July 2009 at 4:38 pm | Permalink

    Thanks very much for the reply to my post Harry. Very educational.

  • 13
    Robert Merkel
    Posted Tuesday, 28 July 2009 at 4:38 pm | Permalink

    Heavy investment in bike infrastructure, which does have a cost, may not translate into long-term rises in bicycling because transport choices are driven by other factors like family and work commitments.

    You knew this would draw out the bike nuts, didn’t you?

    I take your point that it’s very important to make sure that investments in bike infrastructure, like everything else, are value for money.

    But there are plenty of places elsewhere in the world where cycling does work as a mainstream transport choice. And, these days, parts of inner Melbourne are getting very close to that. Back in 2006, in several inner-northern suburbs of Melbourne, over 10% of people cycled to work. Since then, cycling traffic counts have gone up by over 40%. That’s suggesting that the rates are approaching 15%.

    The further point to make is that there has never been a ‘vast investment’ in cycling infrastructure, or calls for it. The kind of money generally talked about is chicken feed - a couple of hundred million bucks a year across the country is about as ambitious as it gets. Roughly the equivalent of a couple of kilometres of freeway.

  • 14
    Michael James
    Posted Tuesday, 28 July 2009 at 6:13 pm | Permalink

    Heavy investment in bike infrastructure”??? Robert Merkel (5.38pm) is absolutely right, this was a very poor choice of adjective. If we spent 5% of road investment on bicycle infrastructure would that be heavy? No, but in Brisbane with the current orgy of tunnel and road building, it could amount to almost $1B. You simply do not need such large amounts to build a functional city bicycle system, but we actually spend almost nothing. Here, there are fictious $100M budgets but no one is fooled by a few lines painted on roads. This weekend saw the official opening of the 1km (a puny 1km, costing $200M) busway extension at the main hospital. It includes a (incomplete) fancy bikeshed ($8M! for which they are going to charge users if they get any) but all the so-called bikeways stop hundreds of metres both sides of it (and naturally the place has a moat of traffic around it) — one has to laugh it is so Kafkaesque. And of course bikeways are a preventive budget measure — it saves $billions on extra road capacity, just like a serious public transport system does.
    Paris has shown how you can do it on the cheap by combining dedicated bus lanes that also are used by bicycles and taxis. And if you can get a bunch of stubborn rioters like Parisians to ride bikes, it can be done anywhere.

  • 15
    JamesK
    Posted Tuesday, 28 July 2009 at 7:08 pm | Permalink

    Interesting slant on this topic from Bernard Keane.

    Conservative Mark Steyn commenting today on the health debate in the US:

    the “health care” debate is not primarily about health, which chugs along regardless of how the debate goes: Life expectancy in the European Union 78.7 years; life expectancy in the United States 78.06 years; life expectancy in Albania 77.6 years; life expectancy in Libya, 76.88 years; life expectancy in Bosnia & Herzegovina, 78.17 years. Once you get on top of childhood mortality and basic hygiene, everything else is peripheral – margin-of-error territory.”

    Whatever your political slant he is correct.

    Effective public education relating to the prevention of smoking probably saves money in health care costs but the benefit in other areas of health is extremely dubious.

    Quality of life is the prime advantage of advanced health care. But the potential costs show no limits. Once universal government health care is introduced subsequent elections depend on how much the sides are willing to bid for the electorates vote. Labor always bid more but eventually you end up with deficits, Soviet health care or the NHS where lives really are lost through health care inadequcy.

    We’re nowhere near that stage yet but as Nicola Roxon said last night:

    We have to acknowledge that there are, one: difficult choices to be made about how we spend the existing resources that we have. Two: how do we set up the system to make sure it’s sustainable into the future? And three: have a discussion about what governments should contribute and what individuals should contribute.”

    Surpisingly mature remark from this minister. I hope Rudd’s ‘prevention’ nonsense is not used as a deflection from sober decisions.

  • 16
    Diogenes
    Posted Tuesday, 28 July 2009 at 9:06 pm | Permalink

    There is abundant evidence that almost everything about prevention of CVD in terms of lifestyle is bunkum. The advocates of preventive health endlessly blather on about “prevention is better than cure”. And Bernard is wrong when he says it’s the last decade; I’ve been hearing it since Med School in the 80’s.

    State Health Ministers LOVE the idea of prevention for two reasons:
    1. It means they have an excuse to divert funds from hospitals.
    2. Much, much better they can blame the person with the disease and demonise them. “They are clogging up my hospital because of their lifestyle; it’s their fault and the taxpayer is propping them up. There is no personal responsibility, etc etc”

    Obesity is the latest hysteria. Most overweight people live just as long as everyone else with almost no extra diseases. The morbidly obese is a different matter and have very high mortality rates; of course the response of hospitals is to limit the numbers who have bariatric surgery.

    PS I am skinny, don’t smoke and don’t drink alcohol. And I’m definitely not a conservative.

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